2. 255Plast Aesthet Res || Volume 3 || July 14, 2016
in the wound bed.[4]
It follows the principles of skin graft
healing and can therefore be easily incorporated into
host tissue as a suitable alternative. These properties
make alloderm an excellent support material for breast
reconstruction.
Alloderm has been used since 2005.[5]
Lower pole
coverage was achieved by suturing alloderm to the
caudal aspect of the pectoralis major and at the level of
the inferior and lateral mammary folds. The benefits of
alloderm include reducing implant exposure, visibility
and palpability, preventing window shading, better
defined inframammary and lateral mammary folds, and
allowing for a more natural breast shape.[5]
TECHNICAL NOTE
AlloDerm was initially developed to solve problems with
lower pole coverage. Depending on the size of the breast,
the quantity of alloderm sheets per operation may vary,
leading to increased costs. Meshing alloderm is a novel
technique that increases the surface area of usable ADM
while maintaining structural integrity.
A sheet of alloderm regenerative tissue matrix (LifeCell
Corportation, Branchburg, NJ) measuring 6 cm × 17 cm
= 102 cm2
[Figure 1] and having a thickness of 1.0 mm
± 0.2 mm (thin type) was prepared in standard fashion
by soaking in antibacterial solution and placed on the
skin graft carrier (Zimmer Dermacarrier, Zimmer Surgical
Inc., Dover, OH). The tissue matrix was passed through
the skin graft mesher (Zimmer Surgical Inc.) with a
pre-installed roller blade size of 1.5:1 [Figure 2]. Once
meshed, it measures 9 cm × 17 cm = 153 cm2
, an
increase in surface area of 50% [Figure 3]. The meshed
alloderm is then attached to the chest wall and pectoralis
major muscle with PDS 2-0 sutures (Ethicon Inc.), with a
tissue expander placed underneath [Figure 4].
DISCUSSION
The most widely used technique for breast reconstruction
employs tissue expanders and implants.[6]
When first
described, the expander or implant was inserted under
the pectoralis major muscle to obtain complete sub-
muscular coverage. If not feasible, the serratus anterior
or rectus muscles would be raise to cover the lower
pole of the breast. However, using the serratus anterior
muscle would often times be associated with donor site
morbidity. This includes shoulder pain, weakness and
limitation of shoulder elevation due to serratus anterior
palsy, in addition to other problems such as wound
dehiscence, infection and hematoma formation at donor
site closure.[7]
Therefore, the dual-plane technique was
developed, where the expander or implant was covered
by the pectoralis major superiorly and by the dermis of
the breast inferiorly. This eliminated donor site morbidity,
Figure 1: Native alloderm with dimensions of 6 cm × 17 cm = 102 cm2
and having a thickness of 1.0 mm ± 0.2 mm (thin type)
Figure 2: AlloDerm (thin-type) is processed by the skin graft mesher
Figure 3: Meshed alloderm with new dimensions of 9 cm × 17 cm =
153 cm2
Figure 4: Meshed alloderm is sutured to the pectoralis muscle and the
chest wall
3. Plast Aesthet Res || Volume 3 || July 14, 2016256
but was associated with the pectoralis major migrating
superiorly and causing window shading. In addition, as
the inferior pole is covered solely by a thin skin flap,
there is a risk of implant migration, poor visibility,
palpability, and excessive ptosis. Window shading has
since been corrected with marionette sutures to anchor
the pectoralis major, while the development of alloderm
helped with the problem of lower pole coverage.[2]
Meshing of alloderm is an innovative idea that can decrease
the costs of its use. A recent study looked at the effects
of fenestrating ADMs.[8]
Their results showed that with
fenestrations, the incidence of capsular contractures,
infections and seroma formation were all decreased. Further,
they described improved intra-operative fill volumes and
expansion rate, as well as a decreased number of post-
operative expansions.[8]
While not identical in technique to
meshing alloderm, it does show potential further benefits
for meshing alloderm. By employing a similar technique
used with split thickness skin grafts, we were able to take
a standard 6 cm × 17 cm sheet of alloderm and increase
its area from 102 cm2
to 153 cm2
, an increase of 50%. In our
experience, with an increase of 50% more alloderm available
for use, this amounted to savings of approximately 50% per
sheet of alloderm. Intraoperative findings during the second
stage (expander to implant exchange) show that the meshed
alloderm integrates as well if not better than the standard
unmeshed alloderm. This may be because the overall three-
dimensional surface area of the ADM is increased, allowing
for better integration and neovascularization. Further
correlation with histological analysis and clinical follow up to
compare meshed versus un-meshed ADM is pending.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Gabriel A, Maxwell GP. Evolving role of alloderm in breast surgery. Plast
Surg Nurs 2011;31:141-50.
2. Shimizu R, Kishi K. Skin graft. Plast Surg Int 2012;2012:563493.
3. Jansen LA, De Caigny P, Guay NA, Lineaweaver WC, Shokrollahi K.The
evidence base for the acellular dermal matrix alloderm: a systematic
review. Ann Plast Surg 2013;70:587-94.
4. Chauviere MV, Schutter RJ, Steigelman MB, Clark BZ, Grayson JK, Sahar
DE. Comparison of alloderm and allomax tissue incorporation in rats.
Ann Plast Surg 2014;73:282-5.
5. Glasberg SB, Light D.AlloDerm and strattice in breast reconstruction: a
comparison and techniques for optimizing outcomes.Plast Reconstr Surg
2012;129:1223-33.
6. Wu C, Cipriano J, Osgood G, Tepper D, Siddiqui A. Human acellular
dermal matrix (AlloDerm®) dimensional changes and stretching in
tissue expander/implant breast reconstruction. J Plast Reconstr Aesthet
Surg 2013;66:1376-81.
7. Dumont CE, Domenghini C, Kessler J. Donor site morbidity after
serratus anterior free muscular flap: a prospective clinical study. Ann
Plast Surg 2004;52:195-8.
8. Mowlds DS, Salibian AA, Scholz T, Paydar KZ, Wirth GA. Capsular
contracture in implant-based breast reconstruction: examining the
role of acellular dermal matrix fenestrations. Plast Reconstr Surg
2015;136:629-35.